Advice on handling those last-minute disclosures in your consultations
A 46-year-old man attends complaining of impaired hearing in his left ear. After the appointment he asks: ‘By the way, I want to stop smoking. Is there anything you’d suggest to help?’
The needs of a smoker wanting to quit tobacco can be complex. Open questions, such as ‘Why are you planning to stop?’, can rapidly consume your patient time. So it’s best to use the Ask, Advise, Act model, pioneered by the National Centre for Smoking Cessation and Training (NCSCT).1 The emphasis here is on very brief and clear advice.
First we need to find out whether the patient is ready to commit to a stop smoking programme. If the answer is ‘no’, then he will be updated as a smoker on the system to prompt a conversation in the future. If it’s a ‘yes’, we’ve completed Ask and can begin to Advise.
Rather than explore the reasons why he smokes – commonly it is a combination of habit, physical and emotional association – it’s best just to suggest the most effective way to stop, which is medication and behavioural support. Both of these can be accessed by enrolling on a stop smoking programme.
It’s likely that your primary care setting offers a stop smoking programme, but if not, local stop smoking programmes will generally run for six weeks. Patients attend weekly appointments, discuss the reasons for smoking and look at medication that is available to help them quit.
Alongside behavioural support, stop smoking programmes also offer nicotine replacement therapy (NRT). A combination therapy, such as a nicotine patch and an oral product (mouth spray or gum), is the most effective solution.2 A 12-week course of varenicline is also a recommended option. Smokers are four times more likely to quit if they are enrolled on a stop smoking programme than if they try to stop unaided.2
It is also time to talk positively about e-cigarettes. Evidence is stacking up in favour of vaping as a safer alternative to smoking.3
The final step is to Act. This will involve following whichever referral pathway you have chosen to match a smoker up with a programme, normally recording the patient number and booking the
patient in at the first opportunity. If your location does not offer the service, the NHS Smokefree website has a database of local services, including pharmacies (see resources).
Using the Ask, Advise and Act method can take as little as 30 seconds and has proven to be an effective method to give the smoker the advice they need, while avoiding in-depth conversations that can eat into your limited consultation time.
It’s worth recording that if a specific concern, for example a persistent cough, is brought to your attention, recommend a GP appointment alongside the stop smoking programme.
Kevin Kennie is a stop smoking nurse specialist at Chelsea and Westminster Hospital
- National Centre for Smoking Cessation and Training. Very Brief Advice (VBA) on Smoking: the evidence. Dorchester;NCSCT:2014
- NHS. Stop smoking treatments. London;NHS;2016
- Cahill K, Stevens S, Perera R, Lancaster T. Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database Syst Rev 2013;CD009329
- NHS. Smokefree – E-cigarettes. London:NHS;2017